MEDICARE: SPENCER OVERSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10002116A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063969947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER OVERSEN

Provider Business Mailing Address
First Line	:	919 CAMP ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3051
Country	:	US
Telephone Number	:	574-536-7119
Fax Number	:

Provider Business Practice Location Address
First Line	:	919 CAMP ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3051
Country	:	US
Telephone Number	:	574-536-7119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	05/08/2024

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Directions to “ SPENCER OVERSEN ” Practice Location

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